It is important to do a review of the client and her environment to evaluate social and behavioral factors that affect the client's ability to function. This assessment includes a psycho-social history, determination of current functioning, counseling relative to need, and community referrals for services.
Components of the assessment derived from the interview and updated medical record should include family composition and functioning (strengths and needs0, adjustment to pregnancy and parenting attitudes, perceptions of need for care, support systems of client and family (use of formal and informal resources), cultural issues regarding health care, pregnancy, family relationships, educational level, mental health status and history (family violence, depression, suicidal tendencies, key stressors and life events, maternal stress/anxiety extremes), pertinent medical history (e.g., substance abuse), and environmental needs and resources such as housing, financial resources, employment, clothing ,transportation, child care and community violence.
Ascertain whether the client is experiencing any emotional highs or lows about becoming a parent, or whether she is experiencing increased fatigue or stress, particularly if there are other youngsters at home or if she is employed outside her home. The client may have headaches due to stress or the headaches may be indicative of serious medical problems such as hypertension, proteinuria, or edema of the extremities. In such cases prompt contact with the medical provider is indicated.